Provider Demographics
NPI:1801866454
Name:ROTHE, KELLY SUE (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SUE
Last Name:ROTHE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1240
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28714-1240
Mailing Address - Country:US
Mailing Address - Phone:828-678-9352
Mailing Address - Fax:828-682-7866
Practice Address - Street 1:2 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714-2929
Practice Address - Country:US
Practice Address - Phone:828-678-9352
Practice Address - Fax:828-682-7866
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135R4OtherBLUE CROSS & BLUE SHEILD
NC89135R4Medicaid
NC135R4OtherBLUE CROSS & BLUE SHEILD
NC2335695Medicare ID - Type Unspecified
NCP00252272Medicare ID - Type UnspecifiedPERSONAL PROVIDER #